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									        Agency Name______________________________________________ UWSEM Pathways to Financial Success IDA Program
                                                                                   1. Request for Information Form

                             New Participant File Checklist
       Applicant’s Name: _________________________________________
       Reviewer’s Signature: _______________________________                     Date: ___/__/____

       The UWSEM Pathways to Financial Success IDA Program requires partnering agencies to keep the
       following documents/records on file for new participant and forward all copies to United Way
       for Southeastern Michigan:

       Identity verification:
       A copy of participant’s current driver’s license or state issued picture ID card (parent/child)
       A copy of Participant’s Social Security Card (parent/child)

       Income Verification: (From each adult in participant’s household)
           A copy of participant’s most recent payroll check stub; OR
           Verification of income for the prior 12 months prior to date of application; OR
           A copy of participant’s 1099 forms (if self-employed)

           W-2 forms from all jobs
           Prior year U.S. Income Tax Returns for all members of participant’s household

                 x       Form #          Form Name
                             3           Potential Participant Application
                            4a           Participant Personal Budget/Financial Summary
                             5           Individual Asset Plan
                             6           Participant Beneficiary Designation
                            7a           Financial Institution Participant Release of Information
                             8           Participant Release of Liability
                            8a           Participant Credit Report Release
                             9           Participant Open Account Authorization
                            17           Income Eligibility Calculation Sheet
                       19, 20, or 21     Savings Plan Agreement (Asset Specific)
                                         Credit Score Information

           Money order for participant’s credit report

Application Review

Application reviewed for accuracy:                                             Yes              No
Did applicant file taxes?                                                       Yes             No
       If no, reason
Did any adult (age 18 and over) household members file taxes
         Agency Name: ________________________________ UWSEM Pathways to Financial Success IDA Program
                                                                                                   1a. Participant Checklist
separately in the prior year?                                                       Yes              No

If yes, include this income figure in “Household Income Calculation.” Also, you must make a
copy of this person’s Prior Year U.S. Tax Return and W-2 forms.

Household Income Calculation
Number of household members in prior year _______
Do applicant’s W-2’s add up to the “adjusted gross income” listed in their tax return?
                                                                          Yes                       No           N/A
If no, why? Example: IRA deduction,
Prior Year adjusted gross income for all household members that filed taxes in 12 months prior
       to application $_______
Figure above derived from Line 4 on 1040EZ or Line 18 on 1040A or Line 33 on 1040.
Include all prior year adult household members that filed taxes separately from applicant.

Applicant’s total household income within 200% of federal poverty guidelines?  Yes                       No
Applicant eligible for IDA program?                                                            Yes       No

                                                 Current Status of Applicant

Intended Uses:      Homeownership               Education/Job Training                  Micro-enterprise (small business)

  For Program:                                                 For TANF Fund Use:

  ____Eligible                                                 ____Eligible
  ____Ineligible     Reason: _________________________         ____Ineligible       Reason: _________________________

____Withdrew Application    _____Waiting for documentation    ____ Waiting list        Orientation Scheduled: ___/___/___
Missing Document(s): ________________________________________                  Date Received:_____________________________


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